About the Medical Plan

Eligibility and Enrollment

Basic Plan Features

The Prescription Drug Program

Mental Health and Chemical Dependency Care

Covered Expenses

Exclusions

Payments

Claims

Culture of Health/Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

Please note: These charts provide only a brief summary of benefits under the POS II "A" and POS II "B." They are not intended to include all provisions. Non-network and out-of-network area benefits are subject to reasonable and customary limits.

ExxonMobil Medical Plan POS II "A" Option 2012 Summary of Benefits Plan Code: 1021
Service Area: Worldwide Group Number: 476599 Member Services: 800-255-2386 Provider Website: www.aetna.com Select Choice® POS II when accessing DocFind®

Services	POS II NETWORK	NON NETWORK	OUT-OF-NETWORK AREA
Annual Deductible (Individual/Family)	$500/$1,000	$600/$1,200	$500/$1,000
Out-of-Pocket Maximum (Individual/Family)	$4,500/$9,000	$13,500/$27,000	$4,500/$9,000
Individual Lifetime Maximum	Unlimited	Unlimited	Unlimited
Separate Lifetime Maximum for Bariatric Surgery	$25,000	$25,000	$25,000
Inpatient Hospital Services1	$250 deductible 75% coverage	$500 deductible 55% coverage	$250 deductible 75% coverage
Pre-certification Required for inpatient hospitalization, treatment facility, skilled nursing care, home health care, hospice care & durable medical equipment	Provider initiates	You initiate; $500 penalty for failure to pre-certify inpatient care	You initiate; $500 penalty for failure to pre-certify inpatient care
Outpatient Surgery and Associated Diagnostic Lab and X-ray Services	75% coverage	55% coverage	75% coverage

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Physician Services*
Surgeon/Hospital Doctor Visits	75% coverage	55% coverage	75% coverage
Office Visit  (including most diagnostic lab and X-ray services)2	Primary care: $35 co-pay3 Specialist: $50 co-pay3	55% coverage	75% coverage
Preventive Care  (including most diagnostic lab and X-ray services)2 *PCP selection is not required	100% coverage	100% coverage	100% coverage

Prescription Drugs
Annual out-of-pocket maximum for prescription drugs:			$2,500 per individual / $5,000 per family
	Retail Co-Pay* ** ***			Medco Pharmacy**
	(up to 34-day supply)	Maximum Per Prescription	3rd+ Retail Refill****	(up to 90-day supply)	Maximum Per Prescription
Generic Drugs	30%	$50	55%	25%	$100
Formulary Brand Drugs	30%	$115	55%	25%	$200
Non-Formulary Brand Drugs	50%	$170	75%	45%	$300
* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail co-pays. ** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic co-pay and the difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs. *** You must present Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level. ****Additional 25% coinsurance does not apply to the annual out-of-pocket maximum for prescription drugs.

Services	POS II NETWORK	NON NETWORK	OUT-OF-NETWORK AREA
Emergency Care	$75 co-pay4 75% coverage	$75 co-pay4 75% coverage	$75 co-pay4 75% coverage
Maternity	75% coverage	55% coverage	75% coverage
Chiropractic Care Calendar Year Limit5	$50 co-pay3   $1,000	55% coverage $1,000	75% coverage $1,000

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Mental Health1			Overseas only
Inpatient	$250 deductible 75% coverage	$500 deductible 55% coverage	$250 deductible 75% coverage
	Provider initiates precertification	You initiate precertification;  $500 penalty for failure to pre-certify inpatient care	You initiate precertification;  $500 penalty for failure to pre-certify inpatient care
Outpatient Office Visits	$35 co-pay3	55% coverage	75% coverage
Chemical Dependency1			Overseas only
Inpatient	$250 deductible 75% coverage	$500 deductible 55% coverage	$250 deductible 75% coverage
	Provider initiates precertification	You initiate precertification;  $500 penalty for failure to pre-certify inpatient care	You initiate precertification;  $500 penalty for failure to pre-certify inpatient care
Outpatient	$35 co-pay3	55% coverage	75% coverage
1 Pre-certification is required for all inpatient care, including mental health and chemical dependency. 2 Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography. 3 Not subject to deductible. 4 Charge applied to hospital deductible if admitted. 5 Applies to all chiropractic expenses regardless of network status of provider. IMPORTANT NOTE: This chart provides only a brief summary of benefits under this option. It is not intended to include all POS Il "A" Option provisions. This information is applicable to all non-represented employees participating in the Medical Plan. Applicability to represented employees is governed by local bargaining requirements.